1. Managed Long-Term Care Understanding the Changes to Medicaid Home Care in New York State
Evelyn Frank Legal Resources Program
David Silva, Ass’t. Director & Valerie Bogart, Director
(212)

2. What is Managed Long Term Care?2

3. What is Medicaid Managed Long-Term Care?
Managed (Care)
Long-Term Care
The public health insurance program for the poor, operated by the State
A type of private health insurance company paid a fixed amount per capita to authorize and pay for all covered services (“capitation”)
Home care
Adult day care
Physical therapy
Nursing home
Etc. 3

4. We’ve been here before Remember when there was only ONE Medicare?
Original Medicare

5. Why are we talking about this?
The privatization of Medicaid home care in New York state due to Medicaid Redesign.
Old System
New System

6. Old System Centers for Medicare & Medicaid Services (CMS)
Federal
Centers for Medicare & Medicaid Services (CMS)
Pays 50% of cost
Federal statute, rules, guidance and State Medicaid Plan
State
N.Y. State Department of Health (DOH)
Pays about 45% of cost
State statute, rules, guidance
County
County Dep’t of Social Services (DSS) / NYC Human Resources Admin. (HRA)
Pays about 5% of cost
Determines eligibility, prior approval for services, administers program, contracts with providers
Providers
Paid Fee-For-Service (hourly rate for home care services) by DSS / HRA 6

7. New System Centers for Medicare & Medicaid Services (CMS)
Federal
Centers for Medicare & Medicaid Services (CMS)
Pays 50% of cost
Federal statute, rules, guidance and State Medicaid Plan
State
N.Y. State Department of Health (DOH)
Pays about 45% of cost
State statute, rules, guidance
Managed Care Plan
Private Managed Care Organization is paid predetermined amount per member per month (PMPM)
Plan is at risk for all medically necessary care within benefit package
Plan decides what is medically necessary; contracts with providers
Providers
Paid Fee-For-Service (hourly rate for home care services) by plan 7

8. So what? New bureaucracy New incentives New service delivery system
No more CASA staff (mixed blessing)
Less accountability (if that’s even possible)
New incentives
Fixed payment (“capitation”) per person per month creates financial incentive to contain costs
New service delivery system
Providers of long-term care services must contract with private plans, not government agency 8

9. Managed Care vs. Fee for Service
The government wants to end Fee-for-Service in both Medicaid and Medicare.
FEE FOR SERVICE – like American Express card
Original Medicare or regular Medicaid
Client uses any provider that accepts Medicare or Medicaid – not limited to any network
Provider bills insurance (Medicare or Medicaid) directly
Some services require “prior approval” but many don’t – if doctor prescribes, insurance pays
MANAGED CARE – like having a MACY’s card only
Medicare Advantage or mainstream Medicaid Managed Care
Providers must be in-network, services & specialist referrals must be approved by a Primary Care Provider (PCP)
Provider bills managed care company, not Medicare or Medicaid. If client went out of network, provider may not get paid

10. What changed? 10

11. MLTC will be mandatory
Over the next year, all recipients of Medicaid home care services will be required to enroll in MLTC plans
Only affects dual eligibles (Medicare and Medicaid)
Mandatory enrollment will be phased in gradually from July 2012 through 2013, starting with NYC home attendant cases
Clients have 60 days from date of notice to select an MLTC plan or one will be chosen for them at random

12. Affected Clients Dual eligibles (must have Medicare & Medicaid); and
Age 21 or older; and
Receiving Community-Based Long-Term Care services for >120 days in a calendar year
Personal care (PCA/home attendant)
Certified Home Health Aide (CHHA)
Adult Day Care
Lombardi Waiver (Long-Term Home Health Care Services)
Private-Duty Nursing
Consumer-Directed Personal Assistance Program (CDPAP) 12

13. What will happen to them?
These individuals will be required to join a Managed Long-Term Care plan to receive their Medicaid home care benefits
Clients will receive notices from NY Medicaid Choice stating that they must select a plan or they will be randomly assigned to one
Clients will be given a list of plans from which to choose, which include:
MLTC plans (aka “partial-cap”)
Programs of All-inclusive Care for the Elderly (PACEs)
Medicaid Advantage Plus (MAP) 13

14. Map of Managed Care Medicare Medicaid Home Care Services
Personal Care carve-in
Medicaid Advantage
Mainstream MMC
Medicare Advantage
Home Care Services
PACE
Might have to change doctors/hospitals!
Partial-Cap MLTC
MAP
Dental, vision, hearing, etc.

15. Client plan options MLTC * Duals receiving CBLTC MAP PACE
* Client will be assigned to MLTC if no selection made. 15

16. Two general types of MLTC plans in NYS
Most managed long term care plans are “partially- capitated” – the benefit package is solely Medicaid- only long-term care services and limited other health services – not all primary care. List follows.
“Full Capitation” – includes all Medicaid AND Medicare services – primary care, acute, hospital, behavioral and long term care services in the benefit package. This means the client might have to change all their doctors/hospitals!
Program of All-Inclusive Care for the Elderly (PACE)
Medicaid Advantage Plus (MAP)

17. Current Enrollment Partial-cap MLTC Plans NYC 5-2012
Name
TOTAL 44,527
VNS CHOICE
10,524
GUILDNET
7,149
ELDERSERVE
5,858
ELDERPLAN (HomeFirst)
5,523
CenterLight (formerly CCM SELECT)
4,152
SENIOR HEALTH PARTNERS (HealthFirst)
3,823
WELLCARE
2,300
INDEPENDENCE CARE SYSTEMS
2,159
AMERIGROUP
1,485
HHH CHOICES (Bronx only)
1,339
Fidelis 5

18. Services authorized by MLTC
Home care:
Personal Care (home attendant)
Consumer-Directed Personal Assistance Program (CDPAP)
Home Health Aide, PT, OT (CHHA Personal Care)
Adult day care, PERS, home-delivered meals
Medical equipment, supplies, prostheses, orthotics, hearing aids, eyeglasses, respiratory therapy
Home modifications
Podiatry, Audiology, Dental, Optometry
Non-emergency medical transportation
Nursing home
Above are partial capitation only.
PACE, MAPlus include more primary and acute medical services

19. Letters from NY Medicaid Choice
Pre-notice 6/2012 to some Manhattan residents – “MLTC coming” - copy attached
First Notice – Enrollment Packet
Notice stating that individual must enroll in an MLTC plan within 60 days or they will be randomly auto-assigned. Includes a list of plans and educational material.
Second Notice
30 days after 1st notice
Third Notice
45 days after 1st notice; includes name of plan to which individual will be auto-assigned
Fourth Notice
60 days after 1st notice; informing individual of auto-assignment

20. When? July August September October November December January 2013
NY Medicaid Choice sends first letters to Manhattan PCA recipients
Manhattan non-responders will be auto-enrolled.
Begin sending letters to Bronx PCA recipients.
Letters go to Brooklyn PCA recipients
Letters go to Queens and Staten Island PCA recipients
Letters to Lombardi, CHHA, adult day, LPN
Q & SI: 60 days
Kings: 60 days
Bronx: 60 days
NY: 60 days
July
August
September
October
November
December
January 2013 20

21. What about CHHA & Lombardi in NYC?
Only “long-term” CHHA clients are required to enroll in MLTC
Short-term clients can continue to receive CHHA services fee-for-service
Once a client enrolls in an MLTC plan, if they require HHA, PT, OT, visiting nurse, etc. it must be provided by their MLTC plan (under contract with a LHCSA)
Long-term CHHA clients won’t receive auto-enrollment letters until January 2013 at the earliest
Lombardi – will be auto-enrolled in NYC in Jan or later
Adult day and private duty nursing – also Jan or later

22. Implementation outside NYC
Phase II
Nassau, Suffolk and Westchester Counties – Anticipated January 2013
Phase III
Rockland and Orange Counties – Anticipated June 2013
Phase IV
Albany, Erie, Onondaga and Monroe Counties – Anticipated December 2013.
Phase V
Other counties with capacity – Anticipated June 2014.
DOH, “Mandatory Managed Long Term Care Enrollment Plan” posted at 22

23. Implementation Schedule
Phase VI
Previously excluded dual eligible groups contingent upon development of appropriate programs:
Nursing Home Transition and Diversion waiver participants;
Traumatic Brain Injury waiver participants;
Nursing home residents;
Assisted Living Program participants;
Dual eligibles that do not require community based long term care services.
DOH, “Mandatory Managed Long Term Care Enrollment Plan” posted at 23

24. Transition
Law requires MLTC plan to provide previous level of services for 30 days pending its new assessment
After the 30 days, State will allow plans to reduce services
Must give written notice and right to a hearing – but not AID CONTINUING beyond end of prior authorization period
Advocates think this violates the Due Process clause of the U.S. Constitution. 24

25. Advocacy Concerns

26. Advocacy Concerns Meeting Needs of High Hour Clients.
Capitation Incentive to Give Low hours – Many MLTC plans in NYC have done heavy marketing to enroll large numbers of low-hour clients. They receive same capitation rate for all clients.
High-need MLTC client can’t transfer to Personal Care/home attendant program. Now, MLTC will be mandatory – will have to fight plan for more hours. Standards for 24-hour care unclear.
See more info at

27. Advocacy Concerns con’d
Consumer appeals/ fair hearings – rights not as clear as in personal care/home attendant program.
Standards for authorizing care – will MLTC plans be required to follow rules established through litigation, i.e.,
can’t use task-based-assessment when client has 24- hour needs (“Mayer-III”)
must provide adequate hours to ensure safe performance of ADLs (NYS DOH GIS 03 MA/003
non-self-directing people eligible if someone can direct care who need not live with them (92-ADM-49)(Illegal “Back-up” requirement).
Cannot terminate services when hospitalized
See &

28. Advocacy Concerns Excess Nursing Home Usage
MLTC benefit package includes nursing home care
Wide variation among MLTC plans in rate of NH admission
People with high-hour needs, or who are difficult to serve due to dementia, etc. are at risk of NH placement
Reporting and State Oversight
With budget cuts, does DOH have staff to monitor plans adequately, collect and analyze data on quality and monitor avoidable institutionalization?
Plans must be required to monitor and report outcomes, quality measures, nursing home placement and

29. Advocacy Concerns
Case Management – will it be more than limiting hours? Will it actually coordinate medical care, ensure access to transportation, other MLTC services?
Disability literacy – understanding needs of people with disabilities, eg. Wheelchair fitting & authorization, “dignity of risk”.
Capacity – Plans now have 37,000 members, will more than double their enrollment from July – Dec Can they do it?
Medicaid applications and recerts – role of CASAs? How ensure home care not disrupted when glitches in recertifications?
See more in advocates letter to DOH, 5/2011*
(under Public Comments)

30. Advocacy concerns - CDPAP
Consumer Directed Personal Assistance Program – state budget requires all MLTC and Medicaid Advantage Plus plans to offer this option.
Until now, only one MLTC plan has voluntarily offered CDPAP (ICS in NYC)
CDPAP has inherent conflict with “managed care” – as it is not a medical model. Unclear whether MLTC plans, which are inherently medical/nursing model, will understand CDPAP and honor consumer choices
See more concerns in advocates letter to DOH 05/2011, 3/12 and 12/11
See more on CDPAP at

31. Check out http://nyhealthaccess.org for updates!
The End
Check out for updates! 31